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Reeducation  and   Rehabilitation  of 
Crippled,  Maimed  and  Other- 
wise Disabled  by  War 


S.     I.     FRANZ,     PH.D.,     M.D.,    LL.D.  * 


UNIVERSITY  of  CALIFORNIA 

LOS  ANGELES 
LIBRARY 


Reprinted  from   The  Journal  of  the   American   Medical  Association 
July  7,   1917,   Vol.   LXIX,  pp.   63  and  64 


COPYRIGHT,    1917 
AMERICAN   MEDICAL  ASSOCIATION 

FIVE  HUNDRED  AND  THIRTY-FIVE  NORTH   DEARBORN  STREET 
CHICAGO 


REEDUCATION     AND     REHABILITATION     OF 

CRIPPLED,     MAIMED     AND     OTHERWISE 

DISABLED     BY     WAR 


SIIKPHERD  IVORY  FRANZ,  Pn.l).,  M.D.,  LL.D 

Scientific   Director,   Government  Hospital   for  the   Insane 
WASHINGTON,     D.     C. 


The  importance  of  the  work  looking  toward  the  rehabili- 
tation of  the  maimed  and  crippled,  using  these  two  terms  to 
cover  the  great  number  of  different  kinds  of  defects  which 
have  been  produced,  is  being  appreciated  more  and  more  by 
the  Belgian,  English  and  French  governments,  and  by  the 
special  physicians  and  others  who  have  been  compelled  to 
deal  with  certain  of  the  problems.  TJiis  is  shown  both  l>y 
the  number  of  institutions  which  have  been  established,  and 
which  are  being  planned,  and  by  the  amount  of  space  in  the 
medical  journals  which  is  given  to  the  consideration  of  the 
various  factors  involved.  More  recently  there  have  been 
numerous  expressions  of  criticism  that  these  matters  were 
neglected  at  the  beginning  of  the  war,  and  many  hopes  that 
more  energetic  measures  would  now  be  taken  to  deal  with 
this  class  which  had  been  neglected. 

As  the  result  of  previous  wars  and  of  accidents  in  indus- 
trial  pursuits  numerous  crippled  and  maimed  have  been  pro- 
duced.  Except  in  relatively  few  cases  these  individuals  have 
been  permitted  to  bear  their  infirmities  as  well  as  they  could, 
and  the  burden  of  their  support  has  fallen  on  their  families, 
or  on  the  state  if  they  became  social  parasites,  beggars,  and 
the  like. 

In  many  cases  these  individuals  have  gravitated  to  the 
poorhouses  or  to  special  homes  for  the  crippled,  where  they 
have  been  supported  mostly  in  idleness.  Now,  however,  it 
is  being  appreciated  that  great  effort,  and  as  concerted  as 
is  possible,  must  be  made  to  limit  the  parasitic  conditions, 
and  to  make  these  relatively  incompetents  as  competent  as 
possible.  For  the  general  welfare  of  the  nation  as  a  whole, 
for  the  comfort  and  the  well-being  of  the  individuals,  a 
laissez-faire  method  of  dealing  with  them  cannot,  and  should 
not,  be  tolerated.  No  matter  whether  or  not  pensions  will 
be  provided  for  partial  or  for  complet*  support,  humanitarian 
and  social  interests  demand  that  something  more  shall  be 
done.  Efforts  must  be  made  to  bring  about  a  functional 
betterment,  for  the  performance  of  those  operations  which 
will  make  the  individual  a  useful  and  a  productive  member 
of  society.  On  the  side  of  the  individual  efforts  must  be  made 
to  prevent  the  mental  attitude  of  dependence  and  of  woe- 
fulness,  and  this  attitude  or  tendency  to  this  attitude  must 
be  replaced  by  one  of  effort,  of  pride  in  accomplishment,  and 
of  self-help. 


1248N7 


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Statistics  are  not  available  regarding  the  number  of  those 
who  require  special  treatment  of  the  nature  of  reeducation. 
That  the  number  is  not  a  small  one,  and  that  in  case  the 
war  'continues  for  any  length  of  time  for  our  troops  the 
number  will  not  be  small  in  these  United  States,  is  evi- 
denced by  the  efforts  which  are  being  made  in  the  countries 
which  have  been  at  war  for  nearly  three  years  to  bring  about 
a  medical  and  public  appreciation  of  the  conditions.  The 
several  conferences  of  the  allied  nations  at  which  the  dif- 
ferent aspects  of  the  general  problems  (medical,  educational, 
scientific,  social,  etc.)  have  been  discussed  have  also  shown 
the  need  of  preparation  for  many  more  than  are  now  taken 
care  of. 

Borne  has  divided  these  individuals  (and  has  grouped  with 
them  certain  others)  into  three  general  classes: 

1.  Those  who,  with   immediate  care,  can  be  made  almost 
perfect.    (This  group  includes  those  who  have  been  operated 
on,  but  who  have  been  compelled  to  remain  quiet  and  almost 
motionless,   and   who   consequently  have   also   suffered    from 
muscular  atrophies  and  ankyloses.     Here  also  come  the  ten- 
don retractions,  the  defects  which  are  due  to  adherent  bind- 
ing cicatrices,  etc.    In  some  cases  it  may  take  as  long  as  six 
months  to  get  an  individual  of  this  class  normal,  or  approach- 
ing his   normal   condition.     Many   of  these   individuals   have 
been  incapacitated  in  the  manner  mentioned  because  of  lack 
of  appreciation  of  the  .possibilities  of  the  production  of  such 
defects.) 

2.  Those  who  are  definitely  educable,  or  who  are  readap- 
table  to  work  of  some  kind,  but  who  cannot  return  to  their 
former  occupations  on  account  of  the  defects  which  have  been 
produced.    (The  class  includes  all  those  who  have  lost  a  part 
of  the  body,  such  as  a  hand,  or  foot,  or  arm,  or  leg,  or  even 
one   or   more   fingers.     In   these    cases   after   surgical    inter- 
ventions,  amputations  and  the  like,  it  may  take  only  three 
or  four  months  to  make  the  individual  as  nearly  normal  as 
he  can  be  made.     This  includes,  of  course,  necessary  ortho- 
pedic appliances.) 

3.  Those  who  are  so  severely  and  extensively  mutilated  and 
infirm  that  nothing  can  be   done  for  them.     (Relatively   few 
of  this  class  will  exist.     Some  of  those  now  thought  to  be 
incapable  of  training  will  be  found  to  be  amenable  to  some 
kind  of  treatment,  and  this  is  one  of  the  problems  which  will 
need  to  be   considered.     Those  who  cannot  be  benefited  by 
treatment  of  any  kind,  edupational  or  otherwise,  will  probably 
have  to  be  kept  as  permanent  wards  in  special   institutions 
or  in  homes  for  disabled  soldiers.) 

It  has  been  estimated  by  Amar  that  if  proper  and  prompt 
treatment  is  available  80  per  cent,  of  the  whole  number  are 
reeducable.  Some  of  those  who  are  not  counted  in  this  classi- 
fication will  probably  be  dealt  with  in  special  institutions 
where  they  may  also  be  educated.  This  is  true  of  the  blind 
and  the  deaf.  Of  the  total  which  he  considers  educable, 
Amar  also  counts  that  at  least  three  quarters  may  be  uncon- 
ditionally returned  to  some  kind  of  gainful  occupation  and 


to  useful  social  life,  after  they  have  been  given  the  training 
which  their  conditions  warrant.  The  remaining  quarter  can 
he  instructed  in  certain  occupations,  and  can  carry  them  out 
for  such  a  period  of  time,  that  will  enable  them  to  be  useful 
although  their  physical  conditions  may  make  them  very  slow 
in  performance  and  may  prevent  their  active  competition  with 
more  normal  individuals.  For  this  last  class,  therefore, 
special  workshops  may  be  required,  special  positions  may 
need  to  be  sought,  and  some  may  need  special  permanent 
care. 

Already  in  France  and  in  England  much  work  has  been 
done  with  the  maimed  and  crippled,  as  has  been  said,  and  the 
kinds  of  occupations  which  have  been  undertaken  by  these 
defectives  are  numerous.  Besides  farming  and  horticulture, 
for  which  many  have  special  aptitudes  and  previous  special 
training  and  for  which  their  infirmities  are  not  prohibitive, 
the  following  occupations  have  been  taught,  or  retaught,  to 
certain  individuals:  clerical  work,  stenography  and  type- 
writing (with  the  necessary  instruction  in  writing,  drawing, 
geography,  arithmetic,  commercial  law,  important  languages 
besides  the  native  language),  carpentry,  wood  turning  and 
carving,  tailoring,  brushmaking,  basketmaking,  shoemaking, 
hook  binding,  trussmaking,  making  orthopedic  appliances, 
locksmithing,  making  chains,  making  mats  and  rugs,  making 
playthings,  working  in  wood  and  in  iron  in  making  articles 
for  ornaments,  plastic  arts. 

It  will  readily  be  seen,  therefore,  that  a  considerable  num- 
ber of  occupations  are  open  to  those  who  have  been  maimed 
or  crippled,  and  that  many  more  will  be  found  in  our  indus- 
trial establishments  there  is  no  doubt.  In  the  selection  of 
an  occupation  there  should  be  considered  carefully  the  tastes 
and  the  previous  aptitudes  of  the  individuals,  their  past  occu- 
pations, the  degree  of  education,  and  great  care  must  be 
exercised  that  caprice  is  not  given  sway,  so  that  an  individual 
select  such  an  occupation  that  it  is  inconsistent  with  his 
infirmity  and  that,  if  not  entirely  inconsistent,  it  is  so  time- 
consuming  that  the  cost  of  reeducation  is  out  of  proportion 
to  any  expected  gains  that  the  individual  may  make  subse- 
quently. In  many  cases  also  it  is  necessary  to  limit  the 
kinds  of  occupations  from  which  selection  may  be  made,  for 
certain  occupations  may  tend  to  increase  an  existing  infirmity 
such  as  a  contracture  or  a  laxity  of  an  articulation  which 
cannot  be  corrected. 

Rochard  has  criticized  the  conduct  of  the  reeducation  wo/k 
in  France,  because  of  the  lackadaisical  methods  which  were 
used  at  the  beginning.  The  corrective  apparatus  was  badly 
conceived,  awkward  and  not  effective  for  its  purpose  in  many 
cases,  and  due  regard  was  not  paid  to  the  individual.  It  is 
important  that  each  individual  be  considered  as  an  individual, 
and  that  he  be  treated  with  that  kind  of  mechanotherapeutic 
measure  that  will  be  best  fitted  to  his  particular  needs,  and 
at  the  same  time  that  if  any  corrective  apparatus  is  needed 
this  should  be  considered  in  relation  to  the  occupation  that 
the  individual  is  to  undertake  as  a  matter  of  rehabilitation 
and  also  in  relation  to  the  defect  which  is  present. 


Perhaps  no  better  general  outline  of  what  is  needed  can  he 
cited  than  that  of  a  commission  of  the  Royal  Society  of 
Medicine  which  has  recommended  as  follows : 

1.  A  service  of  physical  treatment,  consisting  of  hydro- 
therapy,  electrotherapy  (including  roentgenotherapy),  mechan- 
ical treatment,  medical  gymnastics,  and  massage  should  be 
made  available  at  the  earliest  possible  date  for  all  soldiers 
needing  it  who  are  disabled  by  war.  2.  Centers  of  physical 
treatment,  comprising  all  the  foregoing  methods,  should  be 
established  throughout  the  country  on  an  adequate  scale,  and 
wherever  possible  in  association  with  general  hospitals,  so 
that  other  forms  of  special  treatment  and  diagnosis  may  be 
readily  available.  3.  At  such  centers  there  should  be  a  uni- 
form system  of  measurements  and  records.  4.  Centers  of 
reeducation  and  centers  of  physical  treatment  should  be 
closely  associated. 

In  any  consideration  of  the  general  matter  of  reeducation 
and  rehabilitation  one  matter  must  be  given  due  attention, 
viz.,  the  placing  of  the  men  after  the  reeducation  has  been 
completed.  It  would  be  a  waste  of  time  and  effort  if  such 
individuals  were  reeducated  and  they  were  refused  by  the 
public  to  take  advantage  of  their  possibilities.  The  organiza- 
tion of  the  work  must  deal  with  these  matters,  and  perhaps 
with  such  other  things  as  are  being  considered  in  France, 
like  mutual  societies,  organizations,  and  cooperative  endeavors 
for  the  general  benefit  of  the  members.  And  propaganda  for 
the  popularization  of  the  work  of  these  men,  for  their  utiliza- 
tion in  a  variety  of  ways,  should  not  be  too  lightly  considered. 

Dr.  A-mar,  one  of  the  most  noted  of  the  French  leaders  in 
the  movement  for  rehabilitation,  has  protested  against  the 
lack  of  preparation  and  the  failure  to  provide  suitable  facili- 
ties for  the  proper  prosecution  of  the  work  when  the  maimed 
first  came  in.  He  has  insisted  on  the  necessity  for  full 
preparation  and  on  the  necessity  for  careful,  scientific  and 
thorough  work.  In  this  regard  he  has  said :  "The  time  has 
come  for  organizing  the  work  of  the  wounded  in  such  a 
manner  that  each  one  may  take  his  true  place  in  the  social 
machine,  and  contribute  according  to  his  ability."  And.  in 
like  vein,  Regnier,  after  pointing  out  some  of  the  difficulties 
of  the  work  at  the  beginning  has  emphasized  the  need  of 
a  careful  "scientific  organization"  if  the  work  is  to  lie  con- 
ducted for  the  greatest  benefit  of  the  country,  and  of  the 
individuals  who  have  helped  their  country  and  who  desire 
to  be  returned  to  that  condition  in  which  they  may  be  of  the 
greatest  help  to  themselves  and  to  their  fellows. 


124887 


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ANGELES 
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